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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
392701355
Report Date:
12/30/2024
Date Signed:
12/31/2024 08:58:58 AM
Document Has Been Signed on
12/31/2024 08:58 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
CLEO'S HOME 3
FACILITY NUMBER:
392701355
ADMINISTRATOR/
DIRECTOR:
BRELIN, CLEO
FACILITY TYPE:
740
ADDRESS:
1662 DEDINI LN
TELEPHONE:
(408) 512-4890
CITY:
RIPON
STATE:
CA
ZIP CODE:
95366
CAPACITY:
6
CENSUS:
3
DATE:
12/30/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:
Cleo Brelin
TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Unannounced Plan of Correction visit made out to this facility on 12/30/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Cleo Brelin. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 3 residents..
The purpose of this visit was to follow up on the deficiencies that were cited from a prior post licensing visit conducted on 05/02/2024. This visit was to follow up on the Plan of Correction that was due.
The following deficiencies were observed and cited on 05/02/2024:
The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
Plan of Correction clearance letter was printed and a copy was provided to the facility designated Administrator at this time.
There were no further deficiencies observed or cited during today's Plan of Correction visit.
Exit Interview
SUPERVISORS NAME
:
Liza King
LICENSING EVALUATOR NAME
:
Charlie Yang
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/30/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
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